Chapter 7 Triage

Triage is the process of rapidly sorting patients who present to the emergency department (ED) to determine who needs to be seen immediately and who is safe to wait. This process requires the skills of an experienced emergency nurse. Recently, improving the flow by streamlining the triage process has been the focus of many process improvement efforts in emergency departments.

The National Hospital Ambulatory Medical Care Survey, Emergency Department Summary, estimated that 123.8 million visits were made to U.S. emergency departments in 2008.¹

Environment

In today’s busy ED, the triage function has become even more critical. The number of persons seeking medical care in EDs grew by 32% between 1996 and 2006.² This number is expected to continue to grow in light of the aging population, the number of uninsured patients, and issues surrounding access to primary care. In fact, in 2005, 20% of the United States population had made one or more visits to an ED within the past year.² In 2002 The Joint Commission³ released a sentinel event alert that identified EDs as the location for more than half of all reported sentinel events involving patient death or permanent disability because of delays in treatment. In nearly one third of these occurrences, overcrowding was deemed to be a contributing factor. Given this environment, an effective triage process is crucial to the smooth functioning of an ED.

The word “triage” comes from the French word trier, which means to sort or choose. Today, hospital triage refers to the quick sorting of patients who present to the ED for care. The purpose of triage is to put the right person in the right place at the right time for the right reason. The triage concept has been used since Napoleonic times when soldiers wounded in battle were sorted according to injury severity. Those with mortal wounds were separated from combatants who potentially could be saved. The goal of rapid treatment was to maximize survival and return as many soldiers as possible to the battlefield. The triage concept is still in use in the military and has since become a standard part of civilian ED operations.

In the late 1950s and early 1960s, health care delivery models in the United States changed dramatically. Physicians moved away from independent practices and formed office-based practice groups with regular clinic hours. Instead of house calls, patients now were seen by appointment. At the same time, a nationwide move toward medical specialization began, leaving fewer doctors available for primary care. Hospitals were also evolving. As a result of advances in diagnostic technology and the introduction of intensive care units, hospitals assumed a new role, becoming 24-hour medical resources rather than just a place to stay when seriously ill. With the growth of hospital-based services, EDs began to deal with an onslaught of patients, many with nonurgent complaints. The practice of seeing patients on a first-come, first-served basis rapidly became outmoded, so severity-based triage systems were implemented.

Triage Systems

Currently, most EDs in the United States use some type of triage system. These systems differ along a number of key dimensions, including who is conducting the triage, the depth of the assessment, and the amount of information obtained from the patient.

Comprehensive

Comprehensive triage is the most advanced system and is the process currently recommended by the Emergency Nurses Association’s (ENA) Standards of Emergency Nursing Practice, which defines the practice as follows: “The [emergency nurse] triages each patient and determines the priority of care based on physical, developmental, and psychosocial needs as well as factors influencing access to health care and patient flow through the emergency care system.”⁴ The backbone of this approach is the experienced emergency nurse who has completed a competency-based triage orientation process. Advantages of comprehensive triage are highlighted in Table 7-1.

TABLE 7-1 ADVANTAGES OF COMPREHENSIVE TRIAGE

• An experienced emergency nurse greets the patient.

• Patients in need of immediate care are identified quickly.

• A knowledgeable professional performs an assessment.

• Immediate reassurance is provided to the patient and the family.

• First aid and comfort measures are initiated as needed.

• The patient, family, and visitors can be informed about emergency department processes.

• During the assessment, the emergency nurse has an opportunity for patient teaching.

• The emergency nurse decides which area of the emergency department is most suitable for the patient.

• If protocols are in place, medications for fever, pain relief, and tetanus prophylaxis may be administered.

• Emergency nurses may initiate laboratory work and order radiographs based on triage guidelines.

• Waiting patients are reassessed regularly according to departmental policy.

• A strong communication link is maintained between the triage area and the treatment area.

Comprehensive triage systems have policies, procedures, and protocols (or standards) in place to serve as guidelines. The assessment process involves collecting the chief complaint and any other relevant subjective or objective information. The goal of the comprehensive triage assessment is to gather sufficient information to support a triage severity rating decision. Ratings will vary depending on whether the institution is using a two-, three-, four-, or five-level system. The triage nurse documents initial findings in the medical record and reassesses patients according to individual needs and departmental policy. The ENA recommends that the triage encounter take no more than 5 minutes and possibly as few as 2 minutes.

Two-Tiered Triage Systems

In an ideal world every patient would have a triage assessment within minutes of arrival at the ED. Because of high patient volumes, many facilities have recognized that this goal cannot be achieved and instead have adopted a two-tiered system. With this approach the triage process is broken down into steps. First, an experienced triage nurse greets the patient within minutes of arrival and determines the chief complaint while simultaneously conducting a brief assessment of airway, breathing, and circulatory status. This nurse decides whether the patient needs to be seen immediately or can wait safely for further assessment. With this type of system, patients who require immediate care are promptly taken to the treatment area and are registered at the bedside. This system quickly identifies the patient who is not safe to wait. Stable patients have a patient chart initiated by the first nurse, who documents chief complaint and then directs these patients to the assessment nurse. This second nurse completes a more detailed (but focused) evaluation and may initiate laboratory work and radiographic studies according to protocols. In many EDs, the patient is “quick” registered upon presentation. Enough information is obtained to generate a medical record and an identification band and allow diagnostic procedures to be ordered. The registration process is then completed later in the visit, usually at the bedside.

A two-tiered system has several advantages. In crowded EDs, there is legitimate concern that patients who present to the ED with a serious or life-threatening complaint will have to wait to be seen by the triage nurse. The two-tier system’s advantages include the following:

• A patient with a serious complaint is immediately identified.

• The first triage nurse will know every patient in the waiting room and can keep an eye on them.

• The first triage nurse can answer any questions, address changes in patient status, and perform reassessments as appropriate.

• The detailed assessment performed by the second triage nurse builds on the rapid initial assessment. If the patient omitted vital information, the triage decision can always be changed.

Changes to the Triage Process

Recent changes have been made to the triage processes to improve ED flow. Increase in patient volume and the difficulty moving admitted patients out of the ED, are causing many EDs to focus their effort on improving the “door to doctor time”—in other words, the time of patient arrival in the ED to the time the patient is seen by a licensed independent practitioner. The traditional triage process has been identified as a bottleneck or barrier to patient flow, especially when the number of arriving patients overwhelms the triage process and patients end up waiting to be triaged and then registered. Triage bypass and team triage are two efforts to improve ED throughput.

Triage Bypass

One of the solutions to improve patient flow through the ED is the use of triage bypass. When there are open, staffed beds in an ED there is no reason to determine if the patient is safe to wait. The patient does not need to be formally triaged. Instead the patient is screened by the “greeter” nurse to determine the best location for care and then taken directly to an open, staffed bed in the treatment area. An initial assessment, including vital signs, is then completed by the primary nurse and the patient is registered at the bedside. The licensed health care provider sees the patient in a timelier manner. This movement away from the traditional, linear triage process can have a significant impact on patient flow, but it will require a culture change. Most EDs have open, staffed beds at certain times of the day, and it makes sense to bring the patient to the bed as quickly as possible. Triage bypass makes sense during these times and can reduce the queue of patients waiting to be seen.

Team Triage

In a true team triage system, the emergency physician or emergency nurse practitioner and emergency nurse triage the patient together. Based on the triage findings the physician or nurse practitioner will complete the examination and discharge the patient to home or begin the patient evaluation by ordering diagnostic procedures. For example, if the patient needed a radiograph, the test would be ordered at triage. Once the radiograph was completed the patient would be returned to an internal waiting area and never taken to an ED bed. The value of this type of system is that the patient is seen rapidly by a provider during peak hours when there are no open beds. Patients are evaluated in a timely manner. Concerns about this type of system include cost and how patient handoff will occur between the triage team and the treatment area staff.

The goal of triage bypass and team triage is to decrease the time the patient has to wait to be seen by a licensed independent practitioner and to improve ED throughput.

Triage Severity Rating Systems

Several different triage severity rating systems are described in the literature and are used in various parts of the world. Each system has unique features that are described briefly later.

Triage severity rating systems are evaluated along several dimensions; two important considerations are validity and reliability. Validity refers to the accuracy of the triage severity rating system. In other words, how well does it measure what it is intended to measure? Do the different triage levels truly reflect differences in severity? For example, you would expect a high admission rate for patients identified as very ill.

Reliability is another important characteristic of a triage severity rating system. This refers to the degree of consistency (or agreement) among those using the method. Will different triage nurses assign the same patient the same severity level? Over time, will each triage nurse consistently assign similar patients the same severity level? Importantly, criteria for each triage level need to remain constant. A patient’s assigned severity rating cannot vary simply because the department is busy or a particular nurse is performing triage.

If triage data are collected accurately and consistently, an ED can use this information to analyze and trend various patient outcomes such as ED length of stay and hospitalization rates.

A triage severity rating system serves as more than just a means of scoring an individual’s severity of condition; it becomes a language, a precise shorthand, for communicating patient severity to the ED as a whole. Reliable data also make it possible to compare different EDs and to look at changes within an ED over time. For example, staff may report that the pediatric population they are caring for is sicker. ED leadership can look at the case mix data for the pediatric population over time to determine if the staff’s perception is correct. Another example, staff may report that fast track needs to open earlier in the day because so many low-acuity patients are waiting for a long time to be seen. ED leadership can look at arrival time and patient acuity to see if a change in hours is prudent.

Studies have demonstrated poor inter-rater (between different raters) and intra-rater (the same rater on another occasion) reliability with three-level triage severity rating systems.⁵^–⁷ This is largely because there are no universal definitions for each level. Table 7-2 defines two-, three-, and four-level triage systems and the definitions for each triage level.

TABLE 7-2 OVERVIEW OF TWO-, THREE-, AND FOUR-LEVEL TRIAGE ACUITY RATING SYSTEMS

SYSTEM	LEVELS
Two-level	Sick or not sick
Three-level	Emergent: Immediate care required. Threat to life, limb, or organ. Examples: cardiopulmonary arrest, major trauma, and respiratory failure. Urgent: Prompt care required but the patient may wait safely several hours if necessary. Examples: abdominal pain, fractured hip, and renal calculi. Nonurgent: The patient needs to be seen but time is not critical and the patient can wait safely. Examples: sore throat, rash, and conjunctivitis.
Four-level	Life threatening Emergent Urgent Nonurgent

Five-Level Triage

In 2003, The ENA’s Board of Directors approved the following position statement developed by ENA and the American College of Emergency Physicians’ (ACEP) Joint Five-Level Triage Task Force:

ACEP and ENA believe that quality of patient care would benefit from implementing a standardized ED triage scale and acuity categorization process. Based on expert consensus of currently available evidence, ACEP and ENA support the adoption of a reliable, valid 5-level triage scale.⁸

In 2004 the Joint Five-Level Triage Task Force identified the Canadian Triage and Acuity Scale (CTAS) or the Emergency Severity Index (ESI) as good options based on a review of the published evidence on five-level triage systems.⁹

The Joint Five-Level Triage Task Force statement was a large step toward the recommendation and adoption of a single five-level acuity rating system in U.S. emergency departments.

Currently, there are four research-based, five-level triage severity rating scales in use around the world. In each scale, level 1 represents the highest severity (most acute), whereas level 5 is used to designate the patients with the least acute conditions.

The Australasian Triage Scale

The Australian emergency medical community adopted the Australasian Triage Scale in 1993, and it remains in use in every ED in Australia (Table 7-3). Based on research and expert consensus, each category lists clinical descriptors or conditions that correspond to a specific severity level. Objective time frames for physician evaluation are set for each classification. This “time to treatment” is the maximum interval a patient should expect to wait for further assessment and medical intervention. The clock starts when a patient first presents to the ED. The triage nurse selects an Australasian Triage Scale category based on his or her response to the statement: “This patient should wait for medical assessment and treatment no longer than . . .”¹⁰ Vital signs are obtained only if they will assist in making the triage severity decision. Performance thresholds are set for each level and indicate what percent of the time the ED must comply with time-to-treatment goals. Research has shown the Australasian Triage Scale to be valid and reliable.^11,¹² In addition to assigning individual patient severity of condition, this scale has been used to examine case mix and to relate triage levels directly to common outcome measures such as ED length of stay, intensive care unit admission, and resource consumption. Educational materials are available online.¹³

TABLE 7-3 AUSTRALASIAN TRIAGE SCALE

The Canadian Triage and Acuity Scale

A group of Canadian emergency physicians developed the five-level CTAS based on the Australasian system ¹⁴ (Table 7-4). Working with the National Emergency Nurses Affiliation, the tool was adopted as the countrywide standard and has become part of the ED data regularly reported to the Canadian government. The CTAS continues to be updated based on the consensus of the National Working Group, research, and EDs’ experience working with the scale.¹⁵ In 2003 the Canadian Emergency Department Information Systems (CEDIS) published a standardized presenting complaint list.¹⁶ The CTAS adult and pediatric guidelines have incorporated the CEDIS complaint list as well as the concept of first-order and second-order modifiers.¹⁶ The patient’s chief complaint is determined by the triage nurse. This automatically generates a complaint-specific minimum CTAS level, but this level can be altered by the use of objective first- and second-order modifiers. Based on the chief complaint the triage nurse then evaluates first-order modifiers, which are defined as modifiers that are broadly applicable to many different chief complaints. First-order modifiers include vital signs, level of consciousness, pain level, and mechanism of injury. Then second-order modifiers specific to the chief complaint are assessed. The CTAS level assigned is based on the highest level identified by any of the modifiers. Studies have indicated that the Canadian Triage and Acuity Scale is valid and reliable.^17,¹⁸ Standardized educational materials are available online.¹³

TABLE 7-4 CANADIAN TRIAGE AND ACUITY SCALE

The Manchester Triage Scale

The Manchester triage scale was developed in England by a group of emergency nurses and physicians who created a detailed, flowchart-based system. Each triage level is given a name, number, and color code that identifies the target time frame for a patient to see a treating clinician ¹⁹ (Table 7-5). Based on the presenting complaint, the triage nurse chooses from 52 different flowcharts. To arrive at a triage level decision, the nurse follows the flowchart, asking about signs and symptoms (or discriminators). A positive answer to a discriminator determines the severity rating. Documentation consists of simply identifying the presentational flowchart used, which discriminator defined the triage score, and the associated triage level. The Manchester triage scale is used throughout the United Kingdom and updated training materials have been published.¹⁸

TABLE 7-5 THE MANCHESTER TRIAGE SCALE

The Emergency Severity Index

Two American emergency physicians working with a team of emergency physicians and nurses created the Emergency Severity Index (ESI).²⁰ This research-based, five-level scale categorizes patients by severity and expected resource needs (Fig. 7-1). Severity is defined as the stability of vital functions and the potential for life, limb, or organ threat. Resource consumption, a component unique to the ESI, is defined as the number of different resources a patient is expected to consume to reach a disposition. The experienced emergency nurse is capable of estimating resource consumption based on previous, similar patient encounters.

Fig. 7-1 Emergency severity index. HR, Heart rate; m, months; y, years; RR, respiratory rate; SaO₂, oxygen saturation in arterial blood.

Rights were not granted to include this figure in electronic media. Please refer to the printed book.

Like other five-level systems, research has demonstrated that the ESI is valid and reliable.²⁰^–²⁴ The system itself consists of an easy-to-use algorithm designed to rapidly sort patients into one of five mutually exclusive categories. Educational materials include an online course, a training DVD, and a handbook.^25,²⁶

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